Cancer Surgery

Treating Cancer with Surgery

Depending on the type and stage of cancer, surgery is common and often the first form of cancer treatment. The goal is usually to entirely remove the cancer itself. Surgery may be all that is required to cure the disease if cancer is diagnosed in its early stages and has not spread to other parts of the body. Often, however, surgery is part of a treatment plan that may also include chemotherapy, radiation therapy, hormone therapy and/or biological therapy.

It is also common in many types of cancer surgery to remove some of the lymph nodes in the area of the tumor. Lymph nodes are tiny glands located throughout the body that act as filters to help prevent the spread of infection. By examining tissue from these nodes, pathologists can help determine if the cancer has spread to other parts of the body.

Cancer surgeons at Swedish are part of a skilled team that includes anesthesiologists, surgical nurses and technicians. As the largest cancer program in the Pacific Northwest, the Swedish Cancer Institute (SCI) offers the latest surgical tools, technology and procedures available, including:

Minimally Invasive Robot-Assisted Surgery (da Vinci)

Swedish is among just a few in the Pacific Northwest to offer the robot-assisted daVinci® Surgical System. This innovative tool allows surgeons to perform some types of complex, minimally invasive procedures with greater precision while speeding patient recovery. Currently, da Vinci robotic technology is used to perform urologic, coloretal, thoracic, gynecological and cardiothoracic surgeries at Swedish.

Breast Conserving Surgery

Surgery is often required to remove a breast tumor but in many cases, a mastectomy (surgically removing the whole breast) can be avoided. With breast-conserving surgical procedures, such as a lumpectomy, the breast tumor is removed while sparing as much of the breast as possible.

Sentinel-node Biopsy for Breast Cancer

For some women, the sentinel-node biopsy is another option for checking the lymph nodes for spread of the cancer. During this surgical procedure, which is less extensive than lymph-node dissection, only a few (usually 1 – 6) lymph nodes (known as the sentinel nodes) are removed and studied. The sentinel nodes are identified by a low dose radioactive tracer and a blue dye injected before surgery. The sentinel lymph nodes are the most likely lymph nodes to be affected by cancer and are a good indicator of whether the cancer has spread. A sentinel-node biopsy, however, may not be an option if a patient's tumor is large or if the lymph nodes are enlarged or known to be abnormal prior to surgery.

This new, minimally invasive technique originated in Europe and has revolutionized the surgical approach for head and neck cancers. Surgeons are able to remove head and neck tumors through the mouth, rather than cutting through the skin and muscle of the neck. For the patient, risk is greatly minimized and recovery of speaking, swallowing and breathing functions is faster than traditional, invasive surgical techniques.

Swedish Medical Center has pioneered this new approach in the Pacific Northwest to bring the best outcome possible to head and neck cancer patients. Our surgeons have access to the latest endoscopic instrumentation and bleeding-edge lasers, such as flexible carbon-dioxide lasers (OmniGuideTM).

Head and neck surgeons at Swedish offer miminally invasive thyroid and parathyroid surgeries that allows patients to recover more quickly from traditional surgical techniques. In select patients, we are often capable of removing thyroid or parathyroid lesions through an incision on the neck that is less than an inch in length. Traditionally, these incisions are three to four inches long, often altering an individual's self perception. Because scars in the neck can be very visible, minimizing these potential scars can improve the outcome of thyroidectomies and parathyroidectomies.

VATS is a surgical technique that accesses the lung through small incisions—versus the larger incisions required in conventional open surgery. In a VATS procedure, a tiny video camera is inserted through one of these smaller incisions, allowing surgeons to view the lung on a high-definition monitor and pinpoint the area that contains the tumor. Then, using special surgical staplers and clips, surgeons can go in and remove the diseased portion of the lung. Surgeons at Swedish Cancer Institute Thoracic Surgery introduced and pioneered the use of VATS in the Pacific Northwest in 1997.

Diagnosing and Staging Cancer

Surgery may be used as part of the diagnosis process to obtain a biopsy—a study on a small sample of tumor tissue. Sometimes, if a tumor is found to be malignant (cancerous), it will be removed during the same operation.

Surgery may also be used to determine the stage, or extent, of the cancer. Staging establishes if the cancer has grown only within its area of origin, or if it has spread to other areas. Knowing the cancer stage is important for creating the most appropriate treatment plan.

Cancer Risk Assessment & Preventive Procedures

The SCI's Hereditary Cancer Clinic focuses on patients and families at risk for hereditary cancers including—but not limited to—breast, ovarian and colon cancers. The results of genetic testing can significantly influence a patient’s treatment plan, as well as indicate appropriate screening tests and medical procedures for relatives who may be at risk of cancer. Genetic testing results and consultations with SCI's experts may lead a patient to consider preventive procedures, such as:

Prophylatic Mastectomy: Surgically removing one or both breasts may prevent or reduce risk of developing hereditary breast cancer when there is no sign of breast cancer.

Salpingo-Oophorectomy (RRSO): Surgically removing the ovaries and fallopian tubes to prevent or reduce the risk of developing hereditary breast cancer when there is no sign of ovarian cancer.

Reconstructive Surgery

According to the National Cancer Institute, reconstructive surgery is "surgery that is done to reshape or rebuild (reconstruct) a part of the body changed by previous surgery." For example, a woman may consider reconstructive breast surgery after a mastectomy. In the video below, Plastic Surgeon, Dr. Wandra Miles explains what to expect with breast reconstruction.

Microvascular Surgical Reconstructive Surgery for Head and Neck Cancer

Cancers originating in the head and neck region often requires complex extirpative surgeries that lead to massive anatomical defects. These defects not only impact a patient’s self-esteem from a cosmetic standpoint, but they also typically severely alter the patient’s ability to swallow, speak, and breathe. In the past, reconstructive options were limited, and suboptimal cosmetic and functional results were “expected” side-effects of the treatment of head and neck cancers.

Microvascular surgical reconstructive technique (free flaps) is now widely accepted as the method of choice to reconstruct and rehabilitate these patients. For example, when a patient has cancer of the tongue and jaw, it is often necessary to remove the entire tongue and jaw. We now are able to reconstruct the jaw bone and tongue utilizing autogratfs from the patient, such as the fibula (leg bone) or the skin of the thigh or forearm to reconstruct both the jaw bone and tongue.

Reconstructive Surgery - Video Transcript

Hello. My name is Dr. Wandra Miles and I am a Plastic and Reconstructive Surgeon at the Swedish Cancer Institute. I've been asked to talk with you about breast reconstruction following a mastectomy and lumpectomy. In this podcast we will cover the different options and methods of breast reconstruction.

Let's begin. There are three options for breast reconstruction: immediate, delayed, or no reconstruction. The option you choose may depend on many factors an individual may decide upon immediate reconstruction if they would like to avoid waiting to have an additional procedure done. But that may not be the best option for everyone.

Delayed reconstruction may be considered if the pathology of your cancer is not clear and definitive treatment has not yet been determined. Delayed reconstruction may also take place if someone is not sure if they're interested in reconstruction. Delayed reconstruction can be done at anytime from two weeks after the initial surgery to many years after. If radiation therapy is planned reconstructive surgery should be delayed and not initiated until at least six months to one year after the completion of radiation therapy.

Once you decide on having reconstructive surgery then there are two types to choose from. The first is commonly known as autologous tissue, which means that you're using your own tissue. When using your own tissue you generally only need to have one or two additional surgeries. There is no need for surgery in the future once reconstruction has been done. The disadvantage is that there would be more scars, a long recovery time, and potential risks of flap failure.

Flap is literally using tissue consisting of skin, fat, and occasionally muscle. There's also risk that the area you take the skin from on the donor site site could become infected. Also due to the shape of your body, there could be obstacles when trying to use a flap.

The other type of reconstruction involves using implants. This type of reconstruction keeps the procedure as simple as possible with the fastest recovery time. With implants the surgery is usually a shorter duration and you can return to work and your lifestyle much faster. There are no additional scars with implant reconstruction, which is an advantage, but the disadvantage is that additional surgery will be needed in the future to replace the implant due to its life span.

The placement of your implant is not the same as with cosmetic breast enlargement. When mastectomy is done the skin is generally eased off the breast tissue compromising its blood supply to the skin. To clarify, if one puts a fully inflated implant deep to the tissue as done with cosmetic breast augmentation, there is significant risk that the tissue may die due to increased pressure since they're already is a compromised blood supply. This occurs with a mastectomy because there is no longer any breast tissue to protect the skin when the implant is placed. Therefore, a temporary tissue expander is needed. One should think of this as a deflated balloon that is placed in a pocket deep into the skin and muscle. Once the tissue is healed, the balloon is slowly inflated to the correct volume to create the size of mass that one wishes. Then the temporary tissue expander is removed and a permanent implant is placed. The patient has the option of saline or silicone implants. Slicone gel implants are now FDA approved. The life span of the implant is approximately ten years but can last for fifteen to twenty years. Replacing the implant is a simple procedure and can be done as an outpatient surgery.

Moving along, lets talk specifically about the several types of autologous issue which again means using your own tissue that may be used for reconstruction. The goal is to take the tissue from an area that would not cause you any loss of function.

The type of flaps available to consider are pedicle, free or a deep perforator flap. As the type of flap used becomes more complex the complications and the risks are greater. Another option for autologous tissue is the latisimus dorsi pedicle flap. This means that the blood supply is never detached and the flap always has blood supply as it is being harvested.

The function of the latisimus dorsi muscle is forearm extension, but one has other functions that can maintain this function once the flap is harvested. This flap would not be the best option for individuals who are avid swimmers, golfers, tennis players, or who would need to use crutches in the future.

The muscle tends to be small in most women. Therefore they most often result in a small A cop and tissue expander or an implant would be needed to achieve volume acceptable to most women.

The TRAM, otherwise referred to as a transverse rectus abdominis myocutaneous taneous flap can be easily a pedical, free, or inferior epigastric perforated flap. The DIEP perforated flap is a type of TRAM flap which consists only of skin and fat and spares the core rectus muscle. This flap cannot be used in individuals whose body habitus is greater than twenty percent of their body fat. It is also not appropriate for individuals who may be too thin and and do not have enough tissue to create a breast. When the flap is used as a pedicle flap both the core rectus muscle and the lower abdominal skin and fat is harvested to create a flap. Again the blood supply is never detached from this pedicle flap.

The biggest risk to this flap is an increased risk of abdominal hernia or bulge due to the loss of the core rectus muscle. To try and minimize this complication the deep perforator flap was created which uses only the skin and fact and the core rectus muscle is left intact in this flap. The blood supply is completely detached and microsurgery is needed needed to restore blood supply to the tissue. As a result this is a more technically challenging flap to perform.

In either of these three flaps the surgery time is longer as well as recovery time. When a lumpectomy is performed there can be asymmetry in breast volume between the breasts as well as a possible contour deformity from radiation therapy.

So if reconstruction after lumpectomies is desired, the recommendation for reconstruction would be to use either autologous tissue, your own tissue.

Finally, you should know that there is risk when undergoing any surgery. Studies have shown that the reconstruction is safe when there's not a high risk for any potential recurrence of the cancer. Also it should be assessed that when a patient is considering reconstruction they need to be aware that it might not be completed in one procedure and they must be willing to deal with the complications that may develop throughout the course of reconstruction.

Thank you for listening to the Plugged in to Your Health cancer podcast program on breast reconstruction.